disease still, though unconsciously, cherishes it; although our improved knowledge of the relation of the nervous system to the organism generally has now made it an anachronism.

2

The words υποχονδριακὸν πάθος, applied by Hippocrates and Galen to the disease, imply a belief that the viscera behind the xiphoid cartilage, and below the diaphragm,1 were its seats; and Galen very distinctly says that black bile is its cause. It is worth while to recall for a moment the physiological ideas which Galen, with great ingenuity, had compounded from the speculations of Plato on the one hand, and Hippocrates on the other. According to Galen, the functions of the human body were maintained by three TVεUμara (whence, remotely, our vapours "). The lowest of these was the TVεvμа quoiкov, and developed the natural force in the liver; the second was the veuμa Zorikov, which elaborated the vital force in the heart; and the third and highest was the πνεῦμα ψυχικόν, which developed animal or soul force in the brain. Anyone who has been curious enough to investigate these questions will see at once that the lowest or "natural" force of Galen is the counterpart of that lowest kind of mortal soul which Plato3 represented as residing in the abdominal organs, and chiefly in the liver, and as having to do with the baser animal passions and the supply of the needs of vegetative life. The ancient tendency to view every source of functional activity as an entityalmost a personality-made it quite consistent for the long succession of Galenist physicians to endow the liver-force with a quasi-consciousness and perception, and even with voluntary activity, though of a low kind; and, on the other hand, the Paracelsian and Helmontian doctrine of the Archæus rather added to than changed anything in the extraordinary power over the general organism which was attributed to the abdominal organs. Then the absence of

The viscera of the hypochondria, to which the ancients attached such importance, seem to have been especially the liver, the pyloric part of the stomach, the omentum, the mesentery, and the spleen. The stomach considered as a whole they regarded rather lightly.

2. De Loc. Affect.,' v. 'De Usu Part.,' v. 'De Usu Resp.,' 163, 164. 3 Timæus,' ed. Stallbaum, §§ 69, 70.

any accurate knowledge of the functions of a central nervous system, the recipient of sensory impressions, and the originator of motor acts, induced men to localise in the various organs the source of the functional disturbances which appeared to be manifested therein. The vagaries of hypochondriacal sensation were therefore, in the ancient view, the perturbations of the natural force generated in the liver, spleen, and pyloric part of the stomach. It is to be remarked, moreover, that hypochondriasis was very generally confounded with hysteria (to which it doubtless has a relation) quite down to the present century. There is nothing surprising in this. The flatulence which is frequently a striking symptom both in hysteria and hypochondriasis was, for the ancients, a commotion of the natural spirits which resided in the abdomen.

It

Of the long list of authors who have treated of hypochondriasis, since the days of Galen, there is scarcely one who viewed the disease in any essentially different light from that in which Galen regarded it, until we come to Thomas Willis, the great investigator of the nervous system. is easy to see what were the common ideas on the subject at the time by consulting that curious book, Burton's Anatomy of Melancholy,' which was published a few years after Willis's death, and which represented the knowledge which a learned and clever layman might pick up without knowing, or without demeaning himself to notice, the writings of a contemporary countryman. Burton says that the general view of authors represents the hypochondriac or windy melancholy as arising " from the bowels, liver, spleen, or membrane called mesenterium," and quotes Laurentius as dividing it into three kinds, the hepatic, the splenetic, and the mesaraick.

Willis, on the other hand, placed hypochondriasis amongst the diseases proper to the diathesis spasmodica; he made it an affection of the nervous system, but so far conformed to the old ideas as to attribute its ultimate causation to im

1 T. Willis, 'Opera Omnia,' 4to, Geneva, 1676. The whole treatise, 'De Morbis Convulsivis,' and that on 'Hysteria and Hypochondriasis' (in reply to the strictures of Nat. Highmore), are astonishing efforts of genius, and will well repay perusal in the present day.

purity of the splenic blood. In the next century, Flemying1 ventured a more distinct opinion that the brain was the part primarily affected, and Cullen2 and Robert Whytt3 (especially the former) placed great stress on the share which the nervous system has in the production of the disease. The next prominent step was taken by Georget* (1819), who protested against the view (at that time still commonly prevailing) of the abdominal origin of hypochondriasis, and the practice of powerful purgation, &c., which was based upon it. But the most complete and effective attack on the old view was made by J. Falret,5 in 1822. This author dwelt strongly on the hereditary character of the disease, and the great frequency with which it is immediately excited by stress of intellectual labour, or by moral and emotional causes. The view of Falret was perhaps carried to excess in limiting the primary seat of the disease so strictly to the brain; but it has prevailed, and hypochondriasis is now commonly placed among the varieties of insanity. Griesinger, for instance, in his admirable treatise on mental diseases,6 makes hypochondriasis a variety of melancholia, which is his first class of "mental diseases characterised by depression;" and Leidesdorf adopts the same view. will be seen that the view which we hold differs in some degree from this; but there can no longer be any doubt that the true seat of the disease is in the nervous centres.

1

It

History. The history of a hypochondriac patient is that of his nervous system under the two aspects of its congenital form and the influences-of nutrition, education, and emotion-to which it has been subjected. So far it is not different from the story of the sufferer from any other form of nervous disease. But hypochondriasis is distinguished

by this, that a more important part is played by the

1 Neuropathia, sive de Morb. Hyperchond. et Hyster,' Ebor., 1744.

26 Clinical Lectures,' London, 1777, pp. 39-57.

3 Observations on the Causes, Nature, and Cure of the Disorders called Nervous, Hypochondriacal, &c.,' London, 1777.

De la Phys. du Syst. Nerv.,' Paris, 1819.

De l'Hypochondrie et du Suicide,' Paris, 1822.

64 Die Path. und Therap. der Psych. Krankheiten,' 2nd edit., Stuttgart, 1861.

7 'Path und Therap. der Psych. Krankheiten,' Erlangen, 1860.

congenital disposition of the nervous system, and a less important part by the physiological and spiritual influences which have been brought to bear on it, than is the case with the majority of nervous diseases. It comes nearest, in this respect, to insanity on the one hand, and to epilepsy and neuralgia on the other. It is the almost inevitable inheritance of a certain percentage of the descendants of any individual who may be very strongly tainted with insanity. On this subject we shall say no more till we can discuss more fully the etiology of this singular disease.

Symptoms. This phrase is pre-eminently appropriate to the phenomena of hypochondriasis. Of physical signs we have almost none to guide us; and this is in perfect agreement with the position which this disorder holds in the category of diseases generally. All is in the region of symptoms. For the most part, too, the symptoms are subjective only; still there are features which the experienced physician can detect, and which can hardly be simulated by a malingerer.

The most important external feature of hypochondriasis is this, that without any sufficient reason for such conduct, and without any signs of intellectual insanity, the patient is observed to concentrate his attention on some particular organ of his body, and to fancy that it is seriously diseased. This concentration of attention is often preceded and accompanied by notable depression or variability of his spirits, with a tendency, on the whole, to depression; this is not always the case, however, for there is sometimes no antecedent symptom connected with the general mental state. In many instances the patient's first sufferings take the form of what he himself considers dyspepsia, but which is in fact little more than flatulence, from the formation of large collections of gas in the stomach and bowels. Along with this flatulence there are sometimes appearances which give a superficial colour to the idea of a primary stomach derangement; the tongue, for instance, is often pasty and coated, and there may be foul breath; the appetite is not unfrequently ravenous, capricious, or well-nigh lost; there is generally obstinate constipation; in rare cases there are even attacks of vomiting.

More commonly there is an antecedent mental change, the character of which it is at first difficult to seize, and which forms one of the grounds for the modern practice of including hypochondriasis in the varieties of actual insanity. Before any local symptoms have declared themselves, the patient has already become changed in his disposition; in most cases, perhaps, the change is simply in the direction of despondency or vague alarm, for which he can give no reason. It is remarked by alienists that the mental condition, even thus early, is characterised above all things by an expansion of the self-feeling, a pre-occupation of the patient with his own condition, to the exclusion of other interests and affections. This is true, but it appears to us that the self-concentration is more like that of a person in the preliminary stage of an acute inflammation or fever, the nature of which is not yet declared, than the egotistic alteration of character which seems to lie at the basis of insanity, and which probably depends directly upon minute changes taking place in the cortical substance of the brain. It is a real bodily sensation (though at first indescribable), which enchains the sufferer's attention; and before long this vague feeling is exchanged for a positive localised sense of uneasiness or actual pain.

Sometimes the early mental state is one not merely or chiefly of despondency, but characterised by suspiciousness and irritability of temper, with quick changes from high spirits and loquacity to moody silence. In any case, after a time, the patient not only exhibits in his aspect and conduct the general uneasiness from which he suffers, but begins to complain of definite subjective symptoms. Probably the most common of these is pain of a gnawing or burning character, or else a sense of great though vague uneasiness But in fact any part of the at the pit of the stomach. peripheral distribution of the sensory nerves may be the apparent seat of painful sensation, and besides this there is very often a general heightened sensibility of the skin. Both the active pain and the heightened sensibility of (uncomplicated) hypochondriasis are subjective, and resemble the similar phenomena which are so common in hysterical women, in vanishing when the patient's attention is power